Excision of Endometriosis

Excise: to cut out surgically; to remove by cutting. Late 16th century (in the sense 'notch or hollow out'): from Latin excis- 'cut out', from the verb excidere, from ex- 'out of' + caedere 'to cut'.-Oxford Dictionaries

Laparoscopic Excision (LAPEX) is the surgical cornerstone of any high quality, multidisciplinary approach to correctly treating endometriosis. LAPEX allows for the disease to be meticulously removed – cut out – from all areas, without damaging surrounding structures or removing otherwise healthy organs. To date, the CEC has treated nearly 6,000 cases from more than 50 countries, performing over 8,000 combined procedures, with excellent long-term outcomes in the majority of our patients. For more on excision, check out "The Case for Surgery for Endometriosis" and "Dr Albee on Excision."

Read on to check out some common endometriosis/excision Q&As below:

Can’t Endometriosis be Diagnosed without Surgery?In a word, no. It is simply not possible to definitively diagnose pelvic pain effectively based on history alone, as endometriosis presents with a unique constellation of symptoms and may be accompanied by other pelvic pain generators in many patients, nor should non-classic signs be undervalued i.e. soft tissue, lung or diaphragmatic disease; bowel or bladder-only symptoms. Dismissing these indications and hindering access to timely surgical diagnosis and treatment only confound the patient’s scenario further. It is of course prudent to rule out differential diagnoses, but physical examination, imaging and lab studies related to an endometriosis diagnosis have extremely poor sensitivity, specificity and predictive values. Hence, they cannot be used to diagnose or rule out the disease. The same holds true for ‘medical diagnosis' - a popular yet flawed trend using a trial course of GnRH agonist or antagonist to ‘see if symptoms are stemmed’ by medical suppression; assuming they are, this is considered by some to be a “diagnosis” and treatment. It is neither. At best, such a course of therapy provides only a temporary means of symptom improvement, not definitive diagnosis or treatment - and often, side effects are significantly negative and intolerable, and may last far beyond the cessation of therapy. Absence of evidence is not evidence of absence.

Similarly, although research has reviewed more than 50 biomarkers related to endometriosis to date, none have been identified as wholly clinically useful [Nisenblat et al.]. A recent evaluation to estimate the diagnostic accuracy of “any combination of non-invasive tests for diagnosis” as replacement tests for surgery and triage tests found that in eleven eligible studies, which included 1,339 participants, ALL were of “poor methodological quality” and “none of the biomarkers evaluated could be evaluated in a meaningful way and there was insufficient or poor-quality evidence. Laparoscopy remains the gold standard for the diagnosis of endometriosis and using any non-invasive tests should only be undertaken in a research setting.” [Nisenblat V, Prentice L, Bossuyt PM, Farquhar C, Hull ML, Johnson N. Combination of the non-invasive tests for the diagnosis of endometriosis. Cochrane Database Syst Rev. 2016 Jul 13;7:CD012281]

In short, true diagnosis is only achieved by surgical intervention; that is to say, Laparoscopy.

Who performs the surgery, how and when is of critical importance, however; excision is a highly advanced surgical technique requiring extensive training. Likewise, accuracy in diagnosis and treatment is dependent on the ability of the surgeon to recognize disease in all its different manifestations. This means, if the surgeon is not familiar with all signs of endometriosis including those less common such as subtle areas of peritoneal tension, atypical clear vesicles, extrapelvic endometriosis, etc. then disease will be missed and left behind untreated; surgeons can only see and treat what they recognize.

Why is Endometriosis So Poorly Managed?To answer this question, one must understand the stark understanding and bias surrounding endometriosis. Often dismissed as simple ‘killer cramps’ that are a woman’s lot in life, or worse, ‘in your head,’ the disease – without question - causes considerable negative impact on quality of life, especially in the domains of pain and psychosocial functioning [Culley L, Law C, Hudson N, Denny E, Mitchell H, Baumgarten M, Raine-Fenning N. The social and psychological impact of endometriosis on women's lives: a critical narrative review. Hum Reprod Update. 2013 Nov-Dec;19(6):625-39]. Endometriosis can also cause physical and psychological damage when left untreated or treated unsuccessfully [Dell'oro M, Collinet P, Robin G, Rubod C. Multidisciplinary approach for deep endometriosis: interests and organization. Gynecol Obstet Fertil. 2013 Jan;41(1):58-64]…yet incalculable misunderstandings and lack of knowledge about the disease persist, propagated by many in the media, the public - and even in our own community.

Clinically speaking, normal endometrium is the lining of the uterus, which breaks down and is shed during menstruation. This normal tissue is histologically different from the ectopic glands and stroma that comprise endometriosis, accurately defined as the presence of functioning endometrial-like – not identical! - tissue in places other than the lining of the womb. [World Endometriosis Research Foundation, World Endometriosis Society et al.] This is an important distinction, as the outdated, incorrect (yet still widely touted) notion that endometrium and endometriosis are the same keeps the disease mired needlessly in – and excuses – delayed diagnoses, oft-needless hysterectomy, poor surgical treatments, ineffective medical suppressives and wholly deficient support of individuals with the disease. Moreover, endometriosis can and does involve and impact the lungs, diaphragm, sciatic region and other notable, extrapelvic areas and is not limited to reproductive organs, and the disease doesn’t only affect menstruating females.

2014 data by Monash University researchers demonstrated once again that significant gaps in care continue to exist, with findings illustrating that fertility continues to remain valued over a patient’s pain, and many patients regularly feel frustration at the lack of effectiveness and side effects of commonly offered treatments. Most importantly, the study revealed what most individuals with endometriosis and pelvic pain already know: patients ‘feel angry and frustrated when they [have] experiences with doctors who misdiagnosed, did not diagnose, delayed diagnosis of endometriosis, or just generally did not listen to their concerns, symptoms, and experiences.’ [Young, Fisher, Kirkman. J Fam Plann Reprod Health Care. 2 September 2014] Still other data reflects what we have known for decades: differing perceptions continue to exist between clinicians vs. patients on pain issues; that instead of lending sufficient attention to patient complaints many clinicians ignore or normalize them; and that education, awareness and disease literacy is sorely lacking even within the highest echelons of the professional community. [Riazi et al. 2014]

In the general healthcare community including at the OB/GYN level, it is taught (and hence practiced) that the most frequent mainstays of treatment are medical suppressives and incomplete surgery. Medication does not eradicate endometriosis, however, and the disease does not simply ‘go away’ as a result of drug suppression. At best, such a course of therapy provides only a temporary means of symptom improvement, not definitive treatment. Often, side effects are significantly negative and intolerable, and may last far beyond the cessation of treatment. Poor outcomes on suppression therapies are routine: drug therapy that can destroy endometriosis permanently has yet to be discovered. Hormonal suppression has “no effect on adhesion of endometriotic cells and cannot improve fertility” [Aznaurova et al.], and success of said therapies may be dependent on localization/type of lesions, with superficial peritoneal/ovarian disease responding better than deep/infiltrative disease. Still, despite evidence to the contrary, some providers prefer medical management and even “diagnosis” by adopting a strategy of ‘treat without seeing’ through medical suppression.

In the majority of such cases, further diagnostic and definitive treatment delays – and patient dissatisfaction – are highly common. The best such medications can do is (sometimes) suppress the disease on a short-term basis, and symptoms undoubtedly recur at cessation of therapy. Suppressive therapies are further limited in usefulness by the length of time they can be safely taken (usually six-twelve months), their high cost, and commonly incapacitating side effects. Hence, the sooner in an individual’s life the disease can be correctly diagnosed and truly eradicated, the better their long-term outlook becomes.

Poor surgical outcomes also remain commonplace. Limited surgery – usually followed by medical suppression - means the patient undergoes both surgery and medical treatment. The patient must still deal with any residual symptoms of the endometriosis left behind. Many times, "limited surgery" results in skimming/burning the top off the area of deep disease, leaving behind the bulk of endometriosis. This is not excisional, and allows for subsequent adhesion formation to bury remaining disease. Disease covered by new adhesions increases pain, leaving a very dissatisfied patient. Burning/ablation, coagulation and other superficial approaches – without or without medical suppression - routinely result in poor outcomes and inevitably require costly reoperation in the future, subjecting the patient to additional procedures, increased expense and surgical risks – yet this sadly remains the ordinary approach to endometriosis.

Superficial surgery only removes the top of the 'iceberg' of disease. Excision removes the entire iceberg.

Still, despite the stark outlook on the disease, there is help and hope!

Surgery (in the proper hands), alternative therapies, diet and nutrition, acupuncture, physical therapy and other complementary treatments can all be helpful at effectively managing symptoms. As noted, we believe high-quality, minimally invasive excisional surgery is the key to building an effective management plan. One need only spend time immersed in the patient population to realize the far-reaching physical and emotional impact of the disease and the toll repeated surgical and medical interventions take, though the literature is often far removed from such first-hand experience(s). Above all, genuine compassion for those who battle this insidious illness must be present. To learn more about endometriosis, click here.

Isn’t Excision Experimental or New?No. Excision for endometriosis is neither new, experimental nor investigational. It is the well-established surgical component of a multidisciplinary approach to treating the disease.

The framework behind the principles of Laparoscopic surgery itself was reported more than a century ago, and throughout the mid 1800's many scientists attempted to construct endoscopic-style instruments. Jumping to the early 1930's, the first reports of Laparoscopic interventions for non-diagnostic purposes were published (initial procedures included lysis of adhesions and biopsies of abdominal organs under direct visualization). After 1986, development of video chips facilitating magnification and projection of the surgical field led Laparoscopic surgery to become the vital part of our surgical discipline it is today. From the first LapCholy performed on a human in 1987 (Mouret) through now, Laparoscopy has “changed the field of surgery more drastically and more rapidly than any other surgical milestone” [Spaner SJ, Warnock GL. A brief history of endoscopy, laparoscopy, and laparoscopic surgery. J Laparoendosc Adv Surg Tech A. 1997 Dec;7(6):369-73].

Even as far back as the 1850s, physicians were noted to ‘dig out the endometriosis nodules with blunt scissors or even with their own fingernails’ [Nezhat C, Nezhat F, Nezhat C. FertilSteril Volume 98, Issue 6, Supplement, S1-S62, December 2012]. TeLinde & Scott further defined the surgical objectives of treatment of endometriosis back in 1952: “one should EXCISE…all evident endometriosis” [emphasis author's]. Superficial techniques, on the other hand, leave disease behind to cause ongoing symptoms and do not provide for histological confirmation of diagnosis – leading to costly and invasive reoperative approaches. Estimates indicate extremely high rates of recurrence for non-excisional surgery; between 40-60% even as quickly as 1-2 years after ablation even with medical suppression post-operatively [Yeung et al.]. In contrast, surgeons utilizing excision report rates of long-term relief in 75-85% of their patients.

Simply: if all endometriosis is not removed at the time of surgery (excised), symptoms will persist, even following hysterectomy; probability of pain persistence post-hysterectomy ranges around 15% and risk of pain worsening is between 3%-5%, with a six-time higher risk of further surgery in those patients with ovarian preservation as compared to ovarian removal. Hysterectomy may even be unnecessary, despite endometriosis being a leading cause of the 600,000 hysterectomies performed annually in the U.S., as healthy tissue and organs may be spared through the Laparoscopic Excision approach [Berlanda N, Vercellini P, Fedele L. The outcomes of repeat surgery for recurrent symptomatic endometriosis. Curr Opin Obstet Gynecol. 2010;22(4):320-325].

Given the technically difficult, highly advanced surgical skills needed, excision should be performed only in specialized high-volume centers by high-volume surgeons; such skill and volume becomes even more critically important when persistent, bowel, bladder and/or extrapelvic disease are involved.

My Surgeon Performed Laser Surgery. Is that Excision? What about Robotic Assisted Surgery? Which is Better?All surgeons - and surgeries - are not equal. Significant confusion often persists around the surgical approaches for endometriosis. The laser is a TOOL – not a METHOD. Laparoscopy is a surgical approach, not a tool. The da Vinci robotic-assisted procedure is also an approach, not a method. Our own surgeons have different preferences that achieve the same ends: total excision of all disease: Dr. Sinervo prefers near-contact Laparoscopy; Dr. Arrington prefers the da Vinci robotic assisted technology. It is important to understand that tool and method are not nearly as important as skill of the surgeon: if he or she cannot excise, they cannot excise using any method or tool. Be sure you know which approach they are using. For example, the laser can be used to safely and successfully perform Laparoscopic resection (excision) of all disease, as we do in our Center – or it can be used to superficially and incompletely burn surface lesions. The approach and tool are not as important as the skill of the surgeon who uses them, and most can be used to facilitate a number of surgical approaches.

Laser ablation and other superficial methods commonly performed by non-excisionists merely char surface tissue, making microscopic evaluation impossible and leaving behind endometriosis - leading to high recurrence and potential complications in future surgical interventions. Excision is not often performed for endometriosis treatment outside the tertiary specialty centers, though the technique has been commonly used for a multitude of surgical conditions almost since the inception of surgery itself, so be sure to ask questions. It’s imperative to determine which method your surgeon will be using and understand their disease knowledge, approach and expected outcomes.

Why Don’t Specialty Centers Accept Insurance?This is a highly misunderstood premise. Many excision centers including ours DO accept insurance, as an out of network provider. We, like other specialists in the disease and various other health subspecialties, are not ‘cash only’ and certainly accept out of network benefits. To better understand insurance and endometriosis care in a specialty center, please read on:

Insurers have requirements for how the doctor practices. Who can they see, for how long, and what can be done for that patient. They incentivize quantity over quality, encourage policy holders to seek cheaper - yet possibly subpar - care with clinicians who do not specialize in the disease and routinely do not reimburse or reward high quality treatment, with complicated reimbursement strategies (and penalties); all done while cutting the patient out of the process.

Surgical destruction of endometriosis by any means shares the same universal billing code (CPT) and henceforth is reimbursed accordingly. That is to say, excision is not - but should be! - categorized as its own CPT, something we have been lobbying for strongly for years; or at the very least, reimbursed accordingly to lesser surgical removal like coagulation, etc. To that end, our the current healthcare system rewards an approach of untreated/poorly treated disease – leading to certain failure and need for retreatment, thus incurring additional costs and subjecting the patient to ongoing care. This contributes greatly to the ever-growing fiscal burden the disease imposes on society. We strongly maintain that bureaucracy must not drive patient care as it does currently, but rather, proven standards of excellence must be the force behind treatment protocols [Hummelshoj].

As we have said for years, reimbursement for endometriosis is a broken system:

No incentives exist to improve quality of - or perform specialized – treatment for endometriosis;

The current system rewards an approach towards untreated/poorly treated disease; and

Surgeons should not be punished or forced to offer subpar care to their patients based on the ill-informed assumptions and decisions made by those who do not understand this disease (e.g. payers).

This protocol is a huge disservice and accounts for lack of reimbursement strategies which would otherwise accurately reflect the true nature of the disease and the critical need for highly skilled surgeons to treat it. Unfortunately, referrals and reimbursements to the specialist centers like ours are often withheld injudiciously due to lack of understanding about the disease and are based loosely on outdated beliefs and unproven concepts, not least of which include the framing of endometriosis as simply normal tissue in abnormal locations (it isn't - endometriosis is profoundly different from the normal endometrium) which is caused by backflow periods, known as Sampson’s Theory (it isn’t), having little if any impact on affected shareholders (it does), able to be easily diagnosed solely by imaging/symptoms and easily treated by long-term hormone therapy or incomplete surgery (it can’t), and cured via hysterectomy/menopause (totally false, outdated assumptions). As a result of these notions that have largely been based on underpowered studies, endometriosis treatment is often ineffective and incomplete.

What being ‘out of network’ means in the context of our practice: we work for our patients, not the insurance companies. Although we are a specialized surgical practice that routinely employs ever-improving teamwork, communication and readiness for our cases, we are able to increase productivity and maximize outcomes while actually decreasing costs. Without the red tape of who/when/how long/what for, we can provide personalized, continuous care to our patients through both quality outcomes and cost-containment – and by working one on one with our patients, offer individualized, compassionate care based on the specifics of their case (this includes discounts to many of our patients). We also do first check, file all the paperwork, handle the appeals and everything an in-network provider would do. Learn more about insurance and treatment at the CEC here.

Is Excision Surgery the Cure for Endometriosis?Medically speaking, "cure" in relation to disease or disorder simply means "to relieve a person of symptoms" [Merriam-Webster]. To that end, excision is the gold standard for surgically treating endometriosis and is highly effective at removing the disease in the majority of those who undergo the procedure. Hence, most patients following excision find their pain is significantly decreased or even completely resolved, for the long term. By that definition, excision is sometimes referred to as 'curative' by some in the community. However, it is also true that not all pain is from endometriosis; that even removing all disease may not solve underlying issues in some cases; and that removal of endometriosis alone will not necessarily address other conditions which lend themselves to pain or symptoms. Perhaps more important than use of the word ‘cure' is addressing each patient’s concerns in a patient-centric, collaborative way to provide the best functional outcome for long-term relief and restoration of quality of life in that individual.

We work with our patients to ensure we are addressing the 'big picture' of their individual situation and routinely engage in collaborative referrals to make sure a true multidisciplinary approach is used. We also strive every day to increase disease awareness, provide training and elevate endometriosis to a priority public platform in order to improve the time to diagnosis and effective, early - and proper - treatment for all those affected. Through timely intervention, individuals can be diagnosed and treated sooner, avoiding the vicious cycle of repeated drug therapies and ineffective surgeries that routinely characterize the disease. By educating society, legislators, insurers and the public, and by training tomorrow's providers, we can empower patients and remove the ubiquitous barriers to care that continue to exist - and one day, make endometriosis a preventable disorder.

In summary, though universal "cure" for every individual with the disease may remain elusive, LAPEX is a critical part of the larger treatment picture for this disease.

I had Excision Surgery but did not obtain relief. Was my surgery a failure?There is perhaps nothing more frustrating and upsetting than feeling like your ‘best-hope-for-relief-surgery’ didn’t work. This is a multifaceted, complex issue that may occur – even following excision in the hands of a “specialist.” We have an extensive article addressing this very topic here.

My Doctor thinks excision & Endometriosis Treatment Centers are all hype and that the disease can be treated by anyone through basic Laparoscopy, drug suppression and down the road, hysterectomy. Do you have any references supporting the use of Excision? Sure! Here is just a small sampling --

"Laparoscopic surgical excision of rectovaginal endometriosis appears to be effective in treating pelvic pain and bowel symptoms and improving health-related quality of life and has a low rate of major complications when performed in specialist centres." Byrne D, Curnow T, Smith P on behalf of BSGE Endometriosis Centres, et al. Laparoscopic excision of deep rectovaginal endometriosis in BSGE endometriosis centres: a multicentre prospective cohort study. BMJ Open 2018;8:e018924. doi: 10.1136/bmjopen-2017-018924

"Surgical excision of endometriosis is an essential tool for the management of symptomatic disease...With appropriate technique, the rate of intraoperative complication, including bowel, bladder and ureteral injury as well as hematoma and bleeding, is approximately 1%. Postoperative complications, including drop in hemoglobin, urinary retention, cystitis, abdominal wall hematoma are usually minor and reoperation rates are well under 1%. Thorough dissection of the retroperitoneum facilitates complete excision of endometriosis with a minimum of morbidity." Gingold JA, Falcone T. The Retroperitoneal Approach to Endometriosis. J Minim Invasive Gynecol. 2017 Mar 3.

"...surgical excision of endometriosis is a feasible and good treatment option for pain relief and improvement of quality of sex life in symptomatic women with endometriosis." Fritzer N, Hudelist G. Love is a pain? Quality of sex life after surgical resection of endometriosis: a review. Eur J Obstet Gynecol Reprod Biol. 2017 Feb;209:72-76.

“The issue of appropriate Laparoscopic surgical training is considered vital and there are strong arguments for standardization of what constitutes the relevant experience and expertise for those undertaking complex Laparoscopic surgery for endometriosis. Crucial aspects in planning Laparoscopic surgery are that surgery should be carried out in the most appropriate setting which can ensure adequate preoperative counseling, appropriate surgical expertise (to ensure the most appropriate procedure is undertaken by the most experienced surgeon at the most appropriate time), adequate technical resources and post-operative support care…It is also important, particularly in cases of more severe endometriosis, that surgeons consider the option of limiting surgical excision at an initial operation in order to refer to a surgeon better equipped to deal with endometriosis, as the first definitive surgical intervention has been shown to deliver the greatest benefit…there is unanimous consensus over the recommendation to excise lesions where possible, especially deep endometriotic lesions, which is felt by most surgeons to give a more thorough removal of disease.” Johnson NP, Hummelshoj L; World Endometriosis Society Montpellier Consortium. Consensus on Current Management of Endometriosis. Hum Reprod. 2013 Jun;28(6):1552-68

Excision vs. Ablation: “One year after laser ablation for painful pelvic endometriosis, 29% of women who continued to be symptomatic were found to have progressive disease and 42% static disease at second look laparoscopy. Many women may undergo additional surgical intervention as a result of persistent or worsening of symptoms. The reoperation rate after laparoscopic treatment of endometriosis has been found to be 21% at 2 years and 58% at 7 years. Endometriosis was most likely to recur close to the original area of involvement, which may be the result of incomplete excision or ablation.” Giudice, Linda, Johannes Evers, DL Healy. Endometriosis: Science and Practice. Chichester, West Sussex: Wiley-Blackwell, 2012. Print.

“Many great debates on the surgical management of endometriosis [exist]…there is general consensus that excision is best for optimal surgical outcome.” - Falcone T, Wilson JR. Surgical management of endometriosis: excision or ablation. J Minim Invasive Gynecol. 2014 Nov-Dec;21(6):969.

“Hormonal suppression improves symptoms, but should not be used to diagnose endometriosis, and is not shown to be effective in preventing disease recurrence nor in improving fertility. The goal of surgical management should be optimal removal or treatment of disease and should include measures for adhesion prevention. Rates of recurrence of endometriosis depend on the surgical completeness of removing the disease.” Yeung P Jr . The laparoscopic management of endometriosis in patients with pelvic pain. Obstet Gynecol Clin North Am. 2014 Sep;41(3):371-83.

“Comparing with incomplete excision, the complete excision of DIE significantly decreased the post-operative pain and the recurrence rate. Although incomplete excision with post-operative GnRHa is efficient with respect to pain, the side effects of the drugs and the recurrence rate after cessation of the drugs must be considered. So complete excision of DIE is the first surgical treatment of choice.” Cao Q, Lu F, Feng WW, Ding JX, Hua KQ. Comparison of complete and incomplete excision of deep infiltrating endometriosis. Int J Clin Exp Med. 2015 Nov 15;8(11):21497-506.

‘In a 24-month follow-up of 240 patients comparing excision alone, laser coagulation alone, or laser coagulation plus medical therapy at 1 year out, results found that 96% of excision patients were pain-free; 69% of coagulation were pain-free. Only 23% of coagulation patients were pain-free at 2 years out.’ Winkel CA, Bray M. Treatment of women with endometriosis using excision alone, ablation alone, or ablation in combination with leuprolide acetate. Proceedings of the Fourth World Congress on Endometriosis, Yokahama, Japan, 1996:55.

“Multidisciplinary laparoscopic treatment has become the standard of care and depending on size of the lesion and site of involvement full-thickness disc excision or bowel resection is performed by an experienced colorectal surgeon. Anastomotic complications occur around 1%. Wolthuis AM, Tomassetti C. Long-term outcome after bowel resection for severe endometriosis is good with a pregnancy rate of 50%.” Multidisciplinary laparoscopic treatment for bowel endometriosis. Best Pract Res Clin Gastroenterol. 2014 Feb;28(1):53-67

“We believe that, besides endometriosis in itself, the overall quality of surgery may have a major role in determining damage to the ovary. In recent years, surgeons dedicated to the treatment of endometriosis have refined the technique of laparoscopic surgery for the excision of endometriomas, with particular attention in developing the correct plane of cleavage and in the judicious use of electrosurgery...Quality of the surgery, and not surgery per se, may be important. Surgery is the gold standard treatment for ovarian endometriomas, but it should be performed with proper techniques by specifically trained surgeons. It's the singer, not the song.” Muzii L, Miller CE. The singer, not the song. J Minim Invasive Gynecol. 2011 Sep-Oct;18(5):666-7.

“Aggressive laparoscopic excision of endometriosis carried out in a specialist center offers good symptom relief, especially for those with severe or debilitating symptoms. To ensure complete removal of all disease, intestinal surgery is required in most patients with complete obliteration of the cul-de-sac.” Redwine DB, Wright JT. Laparoscopic treatment of complete obliteration of the cul-de-sac associated with endometriosis: long-term follow-up of en bloc resection. Fertil Steril. 2001 Aug;76(2):358-65.

“Laparoscopic excision of endometriosis significantly reduces pain and improves quality of life for up to 5 years…[R]eturn of pain following laparoscopic excision is not always associated with clinical evidence of recurrence.” Abbott JA, Hawe J, Clayton RD, Garry R. The effects and effectiveness of laparoscopic excision of endometriosis: a prospective study with 2–5 year follow. Hum. Reprod. (2003) 18 (9): 1922-1927.

“Laparoscopic excision of endometriosis results in a low rate of minimal persistent/recurrent disease. The natural history of endometriosis after surgery suggests a rather static nature of the disease.” Redwine DB. Conservative laparoscopic excision of endometriosis by sharp dissection: life table analysis of reoperation and persistent or recurrent disease. Fertil Steril. 1991 Oct;56(4):628-34.